One line in the final version has received a lot of attention on the twittersphere : "If you identify yourself as a doctor in publicly
accessible social media, you should also identify yourself by name."

Below is the full section from which this comes, followed by the wording of the draft guidance.

Final17If you identify yourself as a doctor in publicly accessible social media, you should also identifyyourself by name.Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely.18 You should also be aware that content uploaded anonymously can, in many cases, be traced back to its point of origin.

Draft17 If you are writing in a professional capacity, you should usually identify yourself. Any material written by authors who represent themselves as doctors are likely to be taken on trust and/or to represent the views of the profession more widely. You should also be aware that content uploaded anonymously can, in many cases, be traced back to its point of origin.

Why has the wording been changed? The GMC have tweeted that the guidance applies "if you are tweeting as a doctor.Then you should identify yourself. Being open+honest helps maintain trust."

The draft guidance was more ambiguous. What was writing in a 'professional capacity'? And you should 'usually' identify yourself. The final guidance is very clear. For people who have not yet started a blog or joined Twitter this clarity may be useful.

But I don't think that many of us who are online already expected this. The RCGP published the final version of its social media highway code last week where they say that as a general principle doctors should use their professional name online if portraying themselves as a registered doctor, but that use of a pseudonym might be reasonable in some circumstances eg moderating a forum, writing about a sensitive subject, or for when comedy or satire.

What happens if a doctor is currently tweeting under a pseudonym and does not start using their real name before April 22nd when the guidance is enacted? Will they be disciplined or reported? How will the GMC respond? Usually most doctors are confident that they are working within the bounds of good medical practice but this is making some with existing pseudonymous twitter accounts, or blogs, feel uncomfortable. They are now deciding what steps they should take.

I have seen some doctors who tweet in their own names suggest that some might use the anonymity of the internet to raise concerns about patient safety or whistle-blow. Personally, I think that writing a blog post to raise concerns about patient safety would be a last resort after taking the steps which the GMC recommend.
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What does this guidance mean to you? I allow anonymous comments on this blog.

EDIT: reaction from around the web@GilulaArc, an orthopaedic surgeon, feels that anonymity is essential to protect those dissenting. She wrote a letter to a magazine in her own name which she feels stalled her career. Read more here.@JobbingDoctor writes that the government sees the professions as people to be controlled. Ensuring doctors only contribute to social media in their own name is part of this. Read more here.
Other reaction collated here.

122 comments:

I, like you, am a GP. I also have a very unusual surname (not so uncommon in Denmark where it originated. So I am very easily traceable, not only by the GMC but also by anyone else who might take a grudge at me! However, I avoid saying anything contentious or libellous. I am not too afraid of the GMC either, as when I reached the age of 66 I relinquished my licence to practise. So they only have limited sanction so far as I am concerned.

Indeed. I have always been clear about my motives for using publicly accessible social media- to connect and learn- so it would not make sense for me not to use my real name. Others who have been using social media under a pseudonym have different aims and objectives.

There are circumstances where a doctor needs to be able to hide their identity from those in authority. The GMC is seen as part of the government system to control and regulate doctors. When doctors have genuine concerns about the NHS services and have been restricted by legal gagging clauses they may need to become anonymous whistleblowers without fear of reprisal from their professional body. To say the GMC have a helpline for whistleblowers is not sufficient as they are seen as part of the system by many doctors

When doctors use a pseudonym to address this type of issue who are they trying to appeal to and what do they hope to achieve? Would it not be better to challenge the gagging clause and speak in their own name?

James, maybe I am missing something. Firstly the reason GMC exists is to prevent government to control who practices and who doesn't and to prevent doctors from being judged by a jury of non-doctors in response to any complaint. The GMC, on balance, protects doctors from government overreach.

Anonymity is important and sometimes necessary but then there are many channels which are anonymous but not public like email, telephone, post which are all open for use. Or maybe as AMC suggests, go ahead speak in your own name. @vgul

You may be thinking of a previous version of the GMC, where the profession elected members. That is no longer the case. The new GMC is a different creature, and it is a creature of government, albeit on a leash of some length.

On a pragmatic level, this is unenforceable. The GMC states "18 You should also be aware that content uploadedanonymously can, in many cases, be traced back to its point of origin," and cites a libel case as evidence for this. However, outside of libel there are few reasons why Facebook or Twitter could be compelled to hand over information that could positively identify the user.

Even if there were legal grounds to do so, who is going to actually legally pursue Facebook or Twitter to reveal the information? And who is then going to pursue the ISPs to translate the information into an actual identity?

GMC guidance works 1st as that- guidance to all of us about what best practice is so that we can align ourselves with the standards of the profession.Next, we feed back to each other when we think that we are not meeting those standards.It is only at a very serious level that a regulator would step in. It would need to be a very serious situation. I agree that obtaining information from 3rd parties would be a very extreme situation.

They would hope to achieve a critical mass of support amongst colleagues as well as patients before exposing identity. It is easy to legally pick off a single 'troublemaker' more difficult to take out a group of individuals who are anonymous until they have enough information to challenge those in authority.The NHS has a long history of gagging its staff and support for this seems to be coming from the very top. The GMC is part of 'the system' whether it likes to see itself in this way. If Doctors risk GMC wrath for being anonymous whilst raising concerns that is a worrying step in the wrong direction.

It comes down to whether doctors trust the GMC when it is seen as part of the same authority system. I suggest some doctors may not have faith that the GMC will be truly supportive and will seek safety in numbers before whistleblowing

I think the guidelines are, in the main, sound, and not a huge departure from what many of us would already see as good practice - i.e. not breaching confidentiality and assuming that no space is secure.

However, I am concerned about the ban on anonymity for anyone declaring themselves to be a doctor. The GMC is late to the party - and there are many doctors already using social media in an established anonymous capacity. Whilst, provided common sense measures have been followed, doctors do not have anything to fear from these guidelines, I think they might turn people off from social media. This would be a shame, given the educational and developmental opportunities, such as #TwitFRG, #GasClass, #FOAMED to name a few. Considering that the GMC (now) have a remit for education since they took on the role of the former PMETB, they should tread carefully and offer appropriate reassurances before turning doctors away from what might be a useful learning medium.

I guess this raises other issues for what it means to be a doctor. Whilst we have certain privileges and responsibilities, being a doctor is part of my life, but not my whole life. I'm sure there will be questions raised about how much control the GMC should be allowed to have over life outside of work. Does an anonymous "Dr" really damage the profession, do they really put patients at risk?

Whilst I agree with the guidelines in the main, I hope they don't damage the new wave of educational initiatives and interprofessional discussions and dialogues on media such as twitter. That would a a great shame and of detriment to the profession, and ultimately to patients.

My main interest in the use of social media has been to connect with other educators and improve medical education. For that reason I have always used my own identity. I'm surprised that you think that real names are a challenge to the initiatives you mention. Surely they support it?

GMC guidance applies to me when I am a doctor. I have a choice to use social media without declaring I am a doctor. But if I do then I don't think it is unreasonable that there should be some clear and unambiguous guidance on best practice.

I can see that there are some exception, but I don't think that education provides many of those. People will be turned of social media if we turn them off. It is up to use to support students, friends and colleagues in discovering how to make the most of these tools, and to point out the pitfalls too.

You are always a doctor, Anne-Marie. You can't turn it off; and why should you have to keep it a secret? You might not wish to comment on anything other than "as a doctor"; and you might never feel it appropriate to e.g. criticise government or GMC or university policy, or to share anything about your personal life.

But the guidelines don't say that you should identify yourself when posting in a professional capacity - they say you should identify yourself if you don't keep your occupation a secret.

Agree with James. Also applies those who wish to use social media for humourous reasons (as the RCGP recommendations say), and those who wish to talk about individual cases. Use of pseudonyms in this case is entirely justified, provided patients and staff can remain anonymous.

How can we improve practice if we can't reflect on it? How can we reflect on how to manage tricky cases if we can't discuss cases?

Of course we need to respect patient confidentiality; one way to enhance this is by commenting anonymously. It is likely that there will be many similar cases; but perhaps not many treated by a specific doctor. This, alone, seems to be a good reason to be able to comment anonymously.

But that's the wrong question. The correct question is, "Why should doctors be denied the ability to make satirical or humorous comments anonymously without keeping the fact that they are a doctor a secret?"

To say "there's no harm in revealing your identity" is naive and silly: we should not have to do so on penalty of losing our livelihood (which is what breach of GMC guidelines can lead to).

I'm sorry you think I'm asking the wrong questions. It is just a healthy curiosity- no judgement is ever entailed in my asking of questions- unlike those who tell me that I am asking the WRONG questions.

The question may not be entirely illegitimate - especially from an observer, like yourself.

But it is the wrong question for the GMC to be asking. If they are planning to say that the default situation is that every doctor who declares themself to be a doctor must also provide their identity, and if they don't they are not complying with GMC regulations... Then they have have a better reason than "you don't need to do that anonymously". Before they are entitled to ask whether or why an activity requires anonymity they are obliged to demonstrate why anonymity is so harmful that it may not be allowed.

As they have singularly failed to do this - comments about "it will tend to make the public trust doctors more" simply don't amount to justification of such a blanket ban on anonymity - it is offensive for the GMC to suggest that if, in somebody's view, anonymity is not essential for the activity, it should be banned.

A more reasonable view would be that doctors are always permitted to post/blog/comment/tweet anonymously unless there's a compelling reason why they shouldn't. (I'm outing myself as a small-l liberal here.) They could then discuss the sorts of reasons that might comprise a compelling reason.

But if we are to remain "professionals" we should retain the right to form a professional judgement for ourselves as to whether these compelling reasons comply in a particular instance.

I'm not asking the GMC questions, I'm trying to understand the views of my peers so that we are in a better position to feedback to the GMC. Clarity is needed and we can start by clarifying our own dis-ease.

I agree that it could have been the other way around. I think people should be able to blog or tweet without revealing their identity if they choose.

Medicine is an applied field. That means, all the discovery work has been done in the lab and hashed out in peer review. It needs to be licensed and regulated so standards of care are adhered to. Its practitioners should take care to stick to the facts when addressing the general public, and if they make statements they ought to be prepared to defend them in a non-anonymous fashion.

Otherwise, the entire biomedical enterprise will fail! We need the trust of the public and its support to succeed in ambitions goals like curing cancer!

But, MDs should also not live in fear of getting fired for saying something incorrect. We have a lot of conversations to have to get the work done, and we shouldn't be afraid of talking to each other.

Actually the big gap in implementing discovery research is in the translation to practice. However it is unlikely that doctors who want to use social media under a pseudonym are doing so because of involvement in research.

Yep. It's really counter-productive to get people riled up about illness.

And, the Public needs to understand that this really is a Team Effort, here. There's not going to be one God-like Smart Person who will Cure All Disease. (You can tell I've been in Germany too long since I am Capitalizing mid-sentence, heh.) We need massive amounts of clever people all working together for cures. (It's different for physics and math- those are not "team sports", so to speak.)

Translating a discovery made in the lab into the clinic in a rigorous and ethical fashion is a lot of work. It requires patience, and a good deal of different experts all communicating with each other. I don't see why the public can't watch (this is not the military here!), but they do need to understand that we cannot always immediately talk to them and, ah, explain what we are saying!

I am a doctor and I tweet about medicine in general and my daily life from one account, I would find it very difficult to separate the two out. I am responsible and careful about keeping to good medical practice, and especially not breaching confidentiality. If I am forced to name myself it will remove my ability to tweet my working life. Imagine the situation where a patient googled my name before an appointment to find that the previous evening I’d tweeted about being tired / late / stressed. I believe that sharing the challenges and difficulties as well as the joy of general practice benefits me, my colleagues and therefore eventually my patients. Being honest humanises the profession to the public, and the contact with far flung and previously unknown colleagues offers an alternative form of support and camaraderie. Removing my ability to be anonymous reduces my ability to do this. It will make it harder to maintain professional boundaries. I feel let down by this new guidance, and it is markedly different to the draft from. I would like more information about what happened in the consultation to result in this change. If the GMC stick to this guidance I will obey it because they are my governing body, and being a doctor is a privilege. However, my opinion of the GMC’s ability to make common sense rational decisions will be severely affected.

Thank you very much for your comment. How would it be if your patients googled your name and saw that you were late/stressed etc? Would it be an issue? What is the benefit of sharing this publicly? I write in my own name but I never thought that this was the sort of thing that I wanted to share publicly with people who do not know me. I don't think it makes me less honest, it's just that I don't find a need. I also don't say anything about my clinical work. I work part-time as a GO so it is easy to tell as on those days I very rarely tweet until late into the evening.

If my patients google my name they will know what I do on the days that I am not in the practice. They might know where I have been on holiday. But generally I keep a lot of my life quite private because I enjoy doing that. It is easier for me personally to work with clear(ish) boundaries about what I want to share with the world and what I want to keep for friends and family.

I've talked about this quite a lot to others and because of that @VictoriaBetton asked me to write something for this guide which she was putting together,Social Media in Mental Health Practice - see page 11 for my account.

Do we need to humanise general practice? I think that patients see me as a human being when they meet me in the consulting room. That is what matters to them.

Jonny Tomlinson is doing a great job of writing about the stresses and strains of general practice, and the joys as well, in his own name. Hopefully he might comment here and tell us about how his patients have reacted to this.

I don't think that writing in my own name makes it harder for me to maintain boundaries. I think it makes it easier. But that is just me.

At the end of the day it is up to us to decide how this guidance applies to use. We may have very good reasons for not following it, but it is always good to think things through.

This is a very interesting topic. As a non-medic I hope you won't mind my joining the conversation. It's always been my belief that as a registered health professional, it's my public duty to declare my registration number to members of the public who request it, so that they are able to check my registration, see any limitations to my practice, or even make a complaint. I think the new guidance might be an attempt to formalise this process. I'm quite happy to share about my personal thoughts and feelings, in addition to my OT expertise, in social media. I find this helps me to enter deeper conversations with people, on a more equal footing; we must be mindful of the power differential that we deliver healthcare along

There's a world of difference between declaring your identity to your patients or those with whom you are interacting _in_your_professional_capacity_; and doing so on social media. If I give advice in my professional capacity of course I identify myself - and my job role and employer; indeed, my email "signature block" includes my GMC number.

As it happens I have never blogged or tweeted anonymously; but I am very angry that the GMC considers that it has the right to tell me that if I do so, I must keep my profession a secret.

As a lawyer (even a non-practising one) I find this guidance extremely chilling in terms of both free speech (Article 10), and the right to a private life (Art 8). I have read through the entire guidance, and I can not find anything anywhere which states that when one becomes a doctor, one becomes a doctor above all else and subjects him or herself to regulation of their entire, not merely professional, life.

With respect to the OP, I think the question needs reframing from 'why would anyone want to be anonymous' to 'why should the GMC encroach in our lives this way'.

I am particularly intrigued by the following passages from the main guidance:

You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.(foreword)

You must use your judgement in applying the principles to the various situations you will face as a doctor (para 4 page 4)

If someone you have contact with in your professional role asks for your registered name and/or GMC reference number, you must give this information to them. (para 64)

and cannot see how the GMC can square these with the guidance on social media. I consider the guidance on social media it to be intrusive and invasive, and against the ECHR. I would be very interested to watch any case the GMC attempts to bring against a doctor refusing to disclose their identity on social media, as I am sure will many of my colleagues, particularly those involved in the digital fight for free speech in line with the convention.

I'm still not clear though. GMC guidance doesn't suggest that a doctor can't tweet under a pseudonym about their private and personal life if they wish. But it does state that if they are tweeting in their professional role, as a doctor, then they should use real name.

If I seeing a doctor comment anonymously on a blog about the NHS are they doing so in their professional role? Should I be able to ask for their GMC number? Or does a

I am not a lawyer. (I have done several masters level modules on law as it applies to medicine, and sessions on defamation and other aspects of the law as it applies to the internet, and training as a trade union representative). I am pleased to hear of your concerns, as I had thought that the guidance breached those articles of the ECHR.

I am angry that the body set up to regulate my profession sees the need to intrude on what I may do in such a way. As it happens, I do not tweet or blog anonymously; but I do feel that I should be permitted to do so if I so choose.

I accept the point made by GMC - that people will trust what we say more if we say who we are. But that should not trump our right to say things anonymously - short, of course, of speech crimes such as defamation or hate speech.

My initial thought was that if I were to be giving e.g. individual medical advice, it might be reasonable to be required to declare who I am; but on further reflection I'm not even convinced of this. If somebody follows medical advice from an anonymous source (who - being anonymous - might or might not really be a doctor), then they are responsible for doing so.

Like NHS GP I might wish, if I were to blog or tweet anonymously, to say that I was a doctor, so that people understand where I am coming from.

Let's say I'm a formula 1 fan, and blog about racing, but my biog states that I'm a doctor working in the NHS. Sure, the fact that I'm a doctor isn't relevant to my blogging on racing; but why should my occupation have to be a secret if I want to blog anonymously?

I might even want to comment on matters relating to medicine. Unless what I am doing is in breach of GMC's Good Medical Practice, why should I be required to identify myself?

I don't think the GMC have thought this through. Your post, Milly, reinforces my view that they will have to withdraw this piece of advice - and that if they don't do so before it faces a legal challenge, they'll be forced to do so by the courts.

Incidentally, I have sought a legal opinion on this from the BMA, and look forward to hearing their views on this.

But it does, Anne-Marie! A doctor may not blog or tweet about their private and personal life if they identify themself as a doctor. Even if what they say has nothing to do with medicine.

And - while my blogging might carry more weight (how much weight does it carry anyhow!) because I say who I am, why should I not have been able (or to be able in the future) to continue publish such articles as I have published on my blog anonymously if I were to choose to do so? (I've listed some of them below.) What right does the GMC to demand that I either keep the fact that I am a doctor secret, or identify myself?

This is draconian and excessive.

Peter

Sample blog posts (not published anonymously - why should I not be able to publish such things anymously?):

Anne Marie, with respect I think you are underestimating the scope of the GMC guidance. It is not confined to doctors tweeting [or posting] in their professional role, as you suggest. The guidance forbids anonymity "If you identify yourself as a doctor in publicly accessible social media". So it's not just a question of when you are posting in your professional role but any time you identify yourself as a doctor. If I chose to comment on the latest Daily Mail "Evil GPs wilfully kill patients on a daily basis" story, I cannot - according to the GMC - identify myself as a doctor and remain anonymous.

The guidance smacks of authors who have no understanding of social media. There is also a disturbing degree of mission creep: by what right or mandate does the GMC regulate my private life except where it affects my professional life? As the lawyer comments above, I cannot see how it is compatible with Article 8 of the ECHR. The GMC's recent records in the courts does not inspire confidence: it has repeatedly had judgements overturned by courts because of poor process or unreasonable decisions.

As others have said above, allowing doctors anonymity can protect patients by protecting whistle-blowers but there is a more fundamental principle at stake: that of personal freedom.

For the record, I have no problem with doctors using pseudonyms. I trust them to use their judgement. I do have reservations about encouraging the use of social media for whistle-blowing. I think that issues of patient safety are too serious for this.

I don't see this guidance as a threat to my privacy however. I see it as the GMC, my professional regulator, laying down its position. In general, we police ourselves first as a profession. Our peers feed back to us as well. It is only in an extreme situation that a complaint reaches the GMC.

At the moment I can not imagine why a doctor would come under the attention of the GMC for not using social media in their own name.

The publication of the guidance has meant that we are considering how and why we use social media. I think that is a very good thing.

Facinating thing is that up until the 1980s the BMA ARM thought that all doctors should retain anonymity in the media. This was to protect patients and so that they would not benefit from a public profile. Although by 1984 some considered this position 'canute-like' http://www.bmj.com/content/289/6447/774

Funny, how times change. At one time anonymity was central to professional standards, now it is contrived as possible attack on them.

@wlancsgp maybe or maybe not a GP -one effect of the GMC's "Guidance" indeed para 17 is something Orwellian, something we might associate with various nasty regimes in places like Bahrain or Belorussia.

It is very interesting to compare the two versions of the guidance pre and post consultation.

Who decided the change and why?The GMC says it wants to encourage openness -well go on then tell us who made the change and why.

It is all about control. The GMC fears and doesn't understand SocMed. Most of all it sees like all autocratic organisations its power slipping away. Drs might be able to communicate anonymously! And so we have the ridiculous para 17 stating that ANYTHING a Dr makes public were it can be inferred the author is a doctor must always carry that drs name.

Note this isn't about when Drs give medical advice but covers everything a Dr communicates where it can be inferred the author is a Dr and it appears in public.

What next the GMC demanding to see my tweets to my wife? My log of fell runs and times that I publish on Garmin Connect? Tweets to Question Time?

The GMC had better start reading up on the EHRA http://www.liberty-human-rights.org.uk/human-rights/human-rights/the-human-rights-act/what-the-rights-mean/article-10-freedom-of-expression.php or it might face some rather large bills.

This regulation specifically para 17 is something no freedom loving Englishman or woman can put up with.

I have the right to write anonymously and I don't have to justify it, it will be for the GMC to justify any limitation to that right and defend its approach.

"What next the GMC demanding to see my tweets to my wife? My log of fell runs and times that I publish on Garmin Connect? Tweets to Question Time?" They aren't demanding, they already see it, its been written in the public domain. They aren't demanding your text messages, or listening to you at the pub. I hope you've got safe zone around your home and work for the garmin.

Well, if it's not mandatory, but just something they're suggesting doctors should think about, they should clarify their guidance to make it clear that no action can be taken against individual doctors just for saying they're doctors, when blogging or tweeting.

They need to say clearly that breaching Good Medical Practice (GMP) is a problem (eg by breaching patient confidentaility); but blogging or tweeting anonymously (while declaring yourself to be a doctor) is not in itself a breach of GMP.

I agree that clarity is needed on what the stance on this guidance is. My understanding is that is just guidance on what GMC think is best practice. But we are all responsible as individuals for making our own decisions on how we practice. If we think we are being professional and appropriate and our peers in the main do to, then I can't see that GMC would be bothered getting involved.

I'm sorry, Anne Marie. I think that's naive. There are plenty of doctors who have been reported to the GMC because somebody's got a grudge against them; and the GMC does not have a good record of quickly dismissing such vexatious reports. A paragraph such as this will provide a very easy way to make doctors' lives a misery.

Look at the literature on whistleblowing. Many are dismissed, suspended, or otherwise disciplined for things that people would not usually think twice about. David Drew was disciplined for sharing an inspirational prayer with a few people; Walker for swearing in a meeting (I've heard much worse from senior people in meetings)... So many people who voice uncomfortable truths are disciplined or sidelined not based on the saying of the uncomfortable truths (the employers know they wouldn't get away with this, although it is the reason why they want to silence the individual), but on some pretext.

This is part of the reason why people may wish to comment anonymously. And the GMC guidelines exacerbate the problem. Imagine this, You voice an uncomfortable truth, fail to keep the fact that you are a doctor secret, and do so anonymously. Your employer wants to silence you for doing so. If they can work out who they are, they can then accuse you of a breach of section 17 of GMP 2013, and they have their pretext for discliplining and silencing you. You've been stitched up by the GMC.

"But how would the person who has a grievance know who the doctor is?"

The GMC guidance is quite correct in stating that it is hard to maintain confidentiality; and if you do tweet or post confidentially, it is likely that you somebody keen enough to identify you and sufficientily resourced will be able to do so. The point here is that if you tweet in confidence and are found out then, regardless of whether there is anything actionable in what you tweeted, the GMC guidance can now be used as a pretext to discipline you or to end your career.

I have been the victim of a vexatious claim against me. I was advised by MPS to suck it up "because if you don't, they'll report you to the GMC and, even if you win, it will take five years out of your life and career".

Like Peter English I am furious about this. And you, Anne, are asking your questions the wrong way round. Not - why do we need anonymity, but - with which justification can the GMC restrict our right to anonymity.

In essence, under the Human Rights Act, the GMC has no business to restrict our rights other than for very well circumscribed reasons. A neboulous -" the public needs to be able to trust" is nonsense. Privacy is a right under the act and restrictions must be justified, proportionate and limited to necessary.

I do not need to justify myself why I share that I am a doctor when I share it and why I prefer to remain anonymous when I choose to do so. If I decide that today I post anonymously, tomorrow under pseudonym No 1 and next day under pseudonym No 2 then this must be entirely my own decision as long as I do not commit a crime.

The only acceptable restriction on anonymity can be the giving of specific, maybe even personal medical advice. But only a fool would do that across the internet on an open forum. And only a fool would follow anonymous advice given across an open forum.

I don't see this as a restriction on privacy. It is guidance. I expect we are free in our professional judgement to ignore what has been decreed as best practice. Can a pseudonymous, or anonymous, doctor bring the profession into disrepute? Personally I doubt it.

With respect to proportionality, a colleague has pointed out this gem from human rights legislation:

"When taking decisions that may affect any of the qualified rights, a public authority must interfere with the right as little as possible, only going as far as is necessary to achieve the desired aim."

First of all, I think people are equalizing being anonymous and being pseudonynous. Those are not quite the same, and most people on social media are pseudonynous rather than outright anonymous.

Secondly, speaking as someone who is not a doctor, or even in the medical field, but who has been involved in social media for a long time, and have occasionally blogged about medical issues, I find these new guidelines extremely problematic. The reason they are problematic, is that they don't take context into consideration at all.

One of the most prominent medical bloggers, blogs under the pseudonym Orac. His blog takes on a lot of quacks and anti-science stances. Him being a doctor, gives some authority to what he writes, but less so than all the science articles he refer. Knowing his real name, would only allow people pushing doubious alternative treatments to try to get him fired. Since his real name is probably one of the worst kept secrets in the science blogsphere, this is exactly what has happened - people contacting his employers to get him fired.

Or maybe I should use a hypothetical situation, which could relate to the UK. Let's say that you are a junior doctor in a hospital which offers long disproved alternative treatments (say, homeopathy). Since alternative treatments are often money-makers, you can't really get the hospital administration to change stance on it, unless they get pressure from the outside. If a junior doctor tries to create the necessary pressure on the hospital through social media, and had to do it under a real name, it would put the doctor's job in jeopardy. Doing it under a pseudonym would, on the other hand, provide some protection against retaliation.

The only case where I think one can reasonably demand doctors to provide real names, are when they give medical advice. Especially personalized medical advice.

My concern with this guidance is around people's approach to using social media. Obviously, there will be some GPs who maintain a separate life outside of work and can draw a boundary, using their twitter account for one or the other or even maintaining two. However, let's say someone has a twitter account called "@ManFromMorcombe" where they tweet about local issues in Morcombe, which is also where their surgery happens to be. They don't tweet about surgery related things (unless its a public event or similar) so there's no worry. Then, one day, during Question Time, they tweet: "Can't believe minister said that. As a doctor I know how patients get cared for #bbcqt"

Bang. They identified themselves as a doctor. Their twitter name identifies their location. Suddenly, they are compelled to state their real name and start using the twitter account professionally?

The result is that @morcombeman simply isn't going to get involved in #bbcqt debate. He probably isn't even going to get involved in tweeting about local issues, just in case. In fact, he'll probably tweet about his favourite football team and the weather, gather 15 followers who know him anyway and never use twitter to do half the things he could do. If @morecombeman decided he would identify himself but also wanted to tweet about his favourite football team and the weather, he might find he can't because patients constaly try and contact him for surgery queries, assuming he is tweeting in a professional capacity.

The result will be, I suspect, that @morecombeman will simply ignore this ruling, making it fairly pointless.

I think the original wording, while being slightly ambiguous, would have got round these problems. If he expressed opinions on #bbcqt it would still be clear he wasn't tweeting in a professional capacity, meaning patients wouldn't have the same expectations.

I say this as someone not involved in medicine at all, so I am happy to stand corrected if anyone has any comments.

My understanding of all @gmcuk is that first of all I decide how to apply the guidance myself. I make a professional judgement. If I was @morcombeman I wouldn't feel I had been in any way unprofessional in the situation I describe. If I was looking on as a fellow doctor I wouldn't bat an eyelid. I can't see that the GMC would care less about something like this.

By the way, after nearly 5 years here blogging and tweeting I have not yet been contacted by a patient. Not one has even mentioned it to me in the surgery.Might change of course.

"And you, Anne, are asking your questions the wrong way round. Not - why do we need anonymity, but - with which justification can the GMC restrict our right to anonymity"

Here, here. It is a fundamental principle of English law that "Everything which is not forbidden is allowed". Doctors do not have to justify their right to anonymity; it is for the GMC to justify why it has curtailed it. It is disturbing that an organisation with quasi-judicial functions can display such disregard for doctors' rights.

I don't think that the GMC can restrict right to anonymity. The question is whether using a real name is always best practice. Many examples are coming forwards which suggest that it might not be. That is why this discussion is useful.

Throwing my hat in: I think anonymity is a bad thing for the current perception of doctors in the public domain. To identify as a doctor is to do so in a professional capacity, and comes with standard behavior expected in the coridors and consulting rooms. If a doctor wishes to have a personal account that is fine, but the mask of the doctor must be removed and left in the consulting room and professional (identified) accounts for the rest. http://goodbyechunkyrice.wordpress.com/2013/03/28/drs-are-anonymous-trying-not-to-be-is-a-dangerous-potato/ Longer, probably no more thought out opinion.

Isn't it ironic. You are posting here, anonymously, saying that doctors should not be able to post things anonymously. You may wish to keep your profession/occupation a secret when you tweet; but if you were a doctor (a registered medical practitioner) the GMC would only allow you two choices: to reveal your occupation and then be required to reveal your identity; or keeping your occupation or profession a secret if you wish to comment anonymously. Why would you accept this? It doesn't mean that you couldn't reveal your identity if you chose to (as I do); but why remove this choice?

Forcing people to reveal their identity if they wish to declare that they're a doctor should only be done if there were a compelling reason. You have not presented such a reason, and I cannot think of one. If you think there is a compelling reason, what is it?

So, breaching the GMC rules is OK if you do it in such a way that they can't catch you? And if they really want to identify you, there's a good chance they'd succeed, even if you thought you were posting anonymously.

I'm not arguing for behaving badly on social media; I'm arguing for not making it an offence to interact anonymously and failing, in the process, to keep the fact that you are a doctor a secret. If S17 is interpreted - as I suspect HR departments looking for some way to get rid of somebody are likely to do - as being an obligation on doctors, and breach of it an offence that could get you struck off and certainly something justifying suspension... then it creates a quite unnecessary jeopardy. I still haven't seen anything that convinces me that this any less than illiberal, disproportionate, and ill-conceived. What is your compelling reason for requiring doctors to choose between identifying themselves completely, or keeping their profession a deadly secret?

Eh? I'm not anonymous, I guess I've not updated my blogger profile. That aside, I've also included links to my own blog, and had it linked to here. The one of my URL's I've used is my name, has my name in the corner and wouldn't take long to find me revealing my College and year of study. And links to my twitter, which is hardly anonymous. If I was trying to be anonymous, I would be doing a bad job. I see it didn't auto hyper link above so here we go: Goodbye Chunky Rice

Next, as I've said lower down and on my post, the only reason I can perceive to refer to your profession is to give weight to your opinion. Or else the people reading would be indifferent to this fact. Therefore it is never possible to not be tweeting in a professional capacity, that being the case people must be held accountable for what they are saying in public to both other professionals and to the public. Both in terms of reputation to the profession, and ensuring what is being said meets other GMC guidelines, the best and most constructive way, imo, is to not allow the very thin veil of anonymity. There is none on the internet.

I've repeatedly said I'm not sure if I support the pedestal doctors are thrust upon, but they don't have a choice, and I'm not sure if its possible due to the limitations of healthcare provision.

As a medical student who uses twitter mainly personally, but does occasionally tweet about issues in medicine or issues related to medicine I think this "guidance" is misguided (sorry for the poor pun!)

Surely doctors, as much as anyone else, have a right to remain private (yes - even if posting on a public website!) particularly when posting about personal issues they may want to share - for whatever reason. Although I do like to use twitter as an educational/news/issues/discussion tool occasionally, I mostly end up tweeting about inane stuff - pictures when travelling, amusing photos or videos I found on the internet or food I'm proud I cooked. Now say I'm qualified, and "outed" on twitter - a patient looked me up after seeing them. They saw I posted an amusing video on twitter which may not be to their liking, or that I believe the church should allow female vicars or that I supported gay marriage - all opinions that could potentially change the doctor-patient relationship.

I think not allowing doctors to be anonymous on twitter opens them up to a lot of potential problems/online abuse - particularly if they like to use twitter as a personal and professional platform. (and surely the great benefit of twitter is that it is both!) Also currently on my psychiatry placement - and my consultant whilst I've been with them has received all kinds of letters from patients (one threat, one love letter, one threatening legal action about their detention) from unwell patients. It made me think whether this could become a problem on twitter if pseudonymity was done away with.

Overall it seems to me there a lot of good reasons why people should be entitled to stay pseudonymous, but few reasons it would cause "distrust." The only situation I could think that distrust may be caused would be if an anonymous doctor was handing out medical advice over twitter - but I would hopefully think if that person was actually a doctor they would know better than to do this!

On another point - who actually comes up with these GMC guidelines? Is it evidence based - as in have their been cases where anonymous doctor tweeters have caused public distrust? Also does this guidance also apply to anonymous medical students on social media?

I can't help thinking that whoever thought up these guidelines must be somebody so po-faced that they can't imagine why anybody would want to post a controversial opinion or a link to an ever-so-slightly-racy video; and who don't understand that maintaining two twitter accounts, including pseudonymous one in which you NEVER EVER mention that you are a doctor, is too complicated for most people.

They also don't care enough about the real reasons why people might wish to be pseudonymous to care, as long as it stamps out bullying! (Which it won't, of course.)

Hello Anon,Thank you very much for your comment. I'm really intrigued by your first comment about whether patients can cope with knowing about our personal lives. It is an issue I raised in this piece I wrote before the publication of the DRAFT guidance. Roo, another medical student, blogged yesterday that he thought that this issue meant that the GMC was correct and that doctors really should keep their identities separate.

I think you raise important points about doctors working in mental health and other areas with vulnerable populations. I was hoping that some of them would write about why they make the decision to participate in social media under a pseudonym. Of course this does not just apply to doctors. Other professionals, such as police office, often decide not to have a social media presence for this reason, and the use of pseudonyms can be considered equally problematic.

With regards to why might pseudonyms build mistrust? I suppose some might think that if a pseudonymous doctor was expressing views about patients which were not kind then this might build mistrust in the profession. However, I believe that this would only reflect poorly on that one doctor. I think that patients decide if they trust doctors when they meet them.

Who comes up with the guidelines? The GMC has said that they made the changes to the draft wording because of responses during the consultation. They did try to get people to engage with the consultation as best they could. I blogged about it! But to be honest, I don't think many saw anything controversial in the consultation. Other such as Dr Grumble, grumbled on my blog about the draft guidance and said he would never reply to the GMC. What did you do?

"whoever thought up these guidelines must be somebody so po-faced that they can't imagine why anybody would want to post a controversial opinion or a link to an ever-so-slightly-racy video;", I don't think that's correct. Its been written by someone who doesn't think a doctor should be posting those things in public.

This isn't a restriction on professional private lives, and is based on the perception of the doctor. I'm not sure if the perception of the infallible doctor is a healthy one, more a comment that the guidelines encourage the maintenance of it. The real debate isn't should doctors be anonymous but what / who is the doctor in modern society.

Time for someone to do a review on what are the most user friendly apps/extensions for managing multiple accounts for professionals with similar problems (lawyers, teachers etc etc etc).

Do you think that anybody should be permitted to post such things in public?

If you accept that some people can, why should doctors not be permitted to do so too?

And if you accept that doctors can do so too, why should they have to conceal the fact that they are a doctor; or to identify themselves if they do so identify themselves?

Do you think that vague ideas - or even clear evidence-based ones - about how people might view doctors if doctors post, under a pseudonym the same sort of vulgar or comic or personal things that others can post are sufficient to curtail doctor's rights?

My understanding of Roo's point is that if a doctor thinks that posting a racy video is going to be harmful to their reputation then then should post it without revealing that they are a doctor, because the GMC may think that this harms the reputation of all doctors, just not the one who is doing the posting.

Peter, I presume that you do not think that the posting of racy videos by a doctor using a pseudonym harms the reputation of all doctors?

"I presume that you do not think that the posting of racy videos by a doctor using a pseudonym harms the reputation of all doctors?"

Yes.

- Doctors are people like anybody else.- Other people need to accept this; it doesn't help to put "doctors" as a group on a pedestal.- If some people find something offensive (while others may find it amusing or entertaining), then those people might think less well of whoever posted it.- But, as long as the posting is not illegal, doctors should have as much right as anybody else to post such things.- And if doctors do choose to post such things, and choose do to do anonymously (as anybody else can), they should not be required to keep their medical registration a secret.

This applies equally to other aspects of doctors' behaviour. As long as their behaviour outside work is legal, it is none of the GMC's business.

Peter - I totally agree. Would never want to have two twitter accounts - that would get very confusing - and besides you would inevitably end up posting something personal on your professional account by accident!

Anne Marie - Thanks for those links! I hadn't seen those - it's an interesting idea. Should the "doctor" and the "person" remain separate? I'm not sure they should - the type of doctor that you are is very much influenced by who you are - your personality/interests/ideas definitely influence the area of medicine that you will end up in! However, saying that, certainly a little restraint is needed - obviously it wouldn't be professional to chat with patients about how drunk you were last night, although it might be appropriate to confess you too enjoy a glass of wine when building a rapport with a patient in order elicit more about their drinking behaviours. It's difficult - I'm sure patients would prefer their doctors to be "real people" and not (as Roo says in their blog) "inhuman." It feels like with this guidance the GMC however is saying we should be keeping the two parts of our lives entirely separate - I don't think thats really something that is possible or realistic.

It relates back to employers looking through candidates facebook profiles - nowadays we all make sure we have the right privacy settings to stop this. You can manage your twitter similarly (by protecting your account - you have to accept all followers and tweets aren't google searchable) Surely having a pseudonym is just an alternative way of doing this without completely locking out the "openness" of twitter that is one of it's benefits.

Yes definitely would be interesting to hear from some mental health/other professionals on their ideas! (Interestingly have other professional governing bodies said similar things? nurses/lawyers etc)I must have missed your blog post on the consultation process. I'm not sure I follow the GMC so wouldn't have seen them promoting it!

"- Other people need to accept this; it doesn't help to put "doctors" as a group on a pedestal."Doctors are put on a pedestal by society, not by themselves. I don't think its necessarily correct to do so, but that is the current existence. The GMC guidance reflects that fairly.

And I don't think doctors can post such things and identify as such. To a large extent a person cannot choose their doctor, should a doctor post something is uncomfortable there is a huge power dynamic at play. In most other cases a person cane easily choose to switch provider if there if there is a serious misalignment of views of acceptability.

Even disregarding that, you seriously think it'd be acceptable for a doctor to be in the canteen staring at the page 3 of the sun? To make a risque joke in the lift? And that just because they haven't the name badge on show that would be acceptable behavior?

I did not respond to the consultation. Too many other things to do; and the original wording (" If you are writing in a professional capacity, you should usually identify yourself") didn't worry me. "Usually" makes it clear that we'd have discretion; and it clearly only applied to writing "in a professional capacity" - which may not be that easy to define, but I'd take it to mean "as part of my job".

The re-worded version is far too inclusive and directive, and I'm sure that if it isn't withdrawn voluntarily by GMC they will be forced to withdraw it by courts - in another humiliation for the GMC.

Fascinating discussion. Just a couple of slightly tangential points if I may?

A doctor speaking anonymously would not have the influence or credibility of one who was identifiable, because who would know whether or not they were really a doctor? Therefore the guidance would be better directed at those who are identifiable, because their words are more likely to influence the reputation/standing of the profession?

I do think we should worry more about why so many feel the need for anonymity. I understand NHS GP's points above, but generally we will not see the shift to a more open culture that most of us wish for until more of us start operating in this way. I am in a position where few speak openly (hospital CEO) whether medical or not (I am) but I do and I have not found it to be disadvantageous in any way. Indeed, like Ann Marie I feel it promotes a better understanding of the issues if the 'human' element is more overt.

I recognise the concerns of whistleblowers but open cultures cannot be mandated - they will come about quickest through mass participation

Offense is subjective. Respect values of others and do not aim to be offensive but do not allow the frame of debate to be set by those offended. Sensitive issues are often the ones least debated and most in need of an open arena for debate.

Anonymous accounts do far more to tarnish the profession's image than open discussion of personal views that can be critiqued. Publish and be damned

I’ve been on twitter for just over a year. I keep my personal and definitely my professional life private. However, in my bio I mention that I am a doctor and why not? It’s my profession and a big part of me. I also have my photo (usually) and my first name there, but under the new guidance that would most likely not be enough.I’d like to think I’m sensible when tweeting and try to behave appropriately. For example remembering not to get involved in character assassinations of politicians or celebrities or ensuring any joke/comment I may retweet wouldn’t bring my professionalism into question. Just this morning I was about to retweet an article from a technology magazine about the new Yahoo App but had to remind myself of one sentence in the article where the author makes personal comments about the teenage boy who has developed the app. I considered it a type of bullying, of which we see a lot on the net, and stopped myself.On a few occasions I have had to politely remind colleagues on twitter of inappropriate comments. On one occasion I was concerned about a possible breach of confidentiality and on another a well-known anonymous medical account with a large number of followers made an insensitive joke after news of an earthquake. This same person once went on to encourage the bullying of a young boy on twitter as part of a huge twitter mob hysteria. On all occasions the authors were rudely dismissive of my concerns. The GMC should maybe concentrate on giving more guidance on self-regulation or how we can deal with situations where we feel colleagues are over-stepping the mark, because in the former case the account was not even anonymous, and in the second the doctor in question could easily be identified.

I don’t consider social media or anonymous blogs the best place for whistleblowing, and also I can see how the GMC would be concerned about someone tweeting as for example “the anaesthetic consultant” anonymously. However, there have been so many times after long, tiring and disheartening shifts at work that I’ve gone home and seen one of these anonymous posts, also voicing my frustration with something that I consider wrong with the system, and have felt slightly comforted. The discussions that these comments usually start can actually be informative, educational and supportive.

We don’t all wish to remain anonymous to cause trouble, we may have personal reasons. I started on twitter to network with other doctors/scientists. As it happened I got more and more involved in Middle-East and Iran politics. Identifying myself as a doctor in my bio rather than having a vague bio with no mention of a profession, has just meant that others know who they are having a discussion with (hopefully an educated person with serious views) rather than a troll, of which there are many. It has helped me connect and be followed by a large number of Iran analysts and journalists who take my views and opinions on the country of my birth seriously. However, my family in Iran have not chosen for me to be vocal and would indeed be in danger if I were too public with my full identity. They live in a country where bloggers are killed in prison and people get prosecuted and punished for the beliefs of their family members.I feel I should have the same right as any other person in this country on how I choose to identify myself publically, and this GMC guideline definitely impinges on my freedom.

Thank you very much for your comment. In the past the default position for doctors speaking in the media was to be anonymous. It was the position of the BMA that doctors should always be anonymous until the mid-1980s at least. In the 1960s people were calling for the GMC to take a stand on this and add it to their guidance as it was felt that they needed to take a stand.

Fast forward 50 years and now the GMC have taken a position in the opposite direction. At this time many do feel that the default position. The concern in the past that a public presence would be a form of advertising is now countered by the GMC saying that we should link to conflicts of interest.

But this is such a new topic, and we are still learning that we will need much more debate such as this before we come to conclusions as individuals and a profession about how to apply this guidance to our practice. I don't think that the guidance can impinge on freedom because it is only that- guidance.

I am not a doctor; so apologies if my unqualified opinion here is also ill informed. But before I make my point, could I just say that I do admire how issues of trust are being debated! I was brought up in a country which has always felt the effects of the absence of this. In my world; as a patient- it is better to have seemingly overbearing watchmen than aloof ones.

I can see both perspectives of this debate- anonymous accounts do post offensive things in the virtual world: derisive opinions on patients, laughing at patient perspectives, and more. The fact these posts are from doctors do make matters worse for all medics. BUT if GMCs guidelines are assuming that the doctor & the person are inseparable then shouldn't they police non-medical activities in the real world?

In my opinion far more damage is done to the profession's reputation by doctors behaving rudely, cruelly, unfairly, and displaying pure hubris in the real world...in their personal interactions with non-medics like me. I find that the GMC don't concern themselves with this unless anything illegal has happened. I recognise the merit of this stance, even if I am disadvantaged by it. Why can it not be the same in the virtual world?

If the GMC guidelines are seen in seclusion, they make a lot of sense. But the world is not ready, in my opinion. Gagging orders, sackings, disciplining, and being put on a proverbial black list are all subject to illogical prejudice. Doctors seem to be under so much pressure already. I wonder if the new guideline will back a cohort of doctors into a corner? Where will their outlet come from? If they tweet without a mask, they court legal action or worse: silent career roadblocks. If they tweet with one they run the risk of starting a beef with the GMC. Is that wise?

It is perhaps not my place to say all this. But in a way I have a vested interest. I would like to continue to be treated by talented, well trained, & happy doctors. I am trying to understand how the social media policy will contribute to that.

As a patient I would like my doctor to be him/herself at all times even when using social media. In my experience that is what makes the person a good doctor. They combine knowlege with humour, understanding and an ability to instantly install trust. I want my doctor to he human and not be in fear of GMC or other recriminations for being honest. Yes protocols have to exist but they should not be seen as constraints.

As a patient I have an obligation to treat my doctor with the respect they deserve whether that is on facebook or in the doctors surgery or on the ward. In my eyes it is simply called common decency. Social media is part of every day life and the way health care is being in delivered now and in the future will be massively different to at any time before. I say embrace those changes, use social media to engage and interact with patients but above all be yourself. Honesty and openness coupled with humility and the traits we all see in our doctors, social media should not change that and the GMC would he stupid to put doctors in handcuffs. Just the view of a patient.....

Great to have your views here. So you would feel able to cope with knowing that your doctor had different political or religious views to you? You don't think that this would impact on your relationship? You wouldn't worry if you saw your doctor say that they had had an exhausting day and were glad to have a glass of wine at the end of the day? I ask as these are some of the things that doctors have said above that they would not feel comfortable sharing with patients, and therefore they would prefer to use eg Twitter without revealing their real name, but still saying that they are a doctor.

If you did see a doctor using social media under a pseudonym what would your reaction be? Would you wonder why they were not revealing their name? Would it make you less trustful of doctors as a whole?

For me my doctor is also a human being and not just a robot. Of course he has political views, has hobbies and likes and dislikes. Why should it bother me and what right do I have to judge. As long as it does not have any detrimental effect on how he treats me then I'm absolutely fine.

I do respect though that my doctor may wish to have a degree of privacy but that is easily managed by what he posts and when. If he gets drunk and at 3am posts a silly picture but is not at work, not on call and in his own time then who am I to criticise. If however his religious or political views clouded the way we interacted then that is different. Again I side on the open and honest approach. Doctors are afterall human beings..

I understand that Twitter helps with staying anonymous but in the current and future digital world it is easy to find things out. I actually believe that a more open and human doctor makes for a better doctor. We always say that politicians don't relate to the real world well sometimes the same can ve said of doctors. Social media helps break down the barriers and also democratises the conversation.

Hi. I have been involved with the virtual world as a doctor for a long time. I was very involved with the Doctors Support Network from early in its existence - a closed email support forum run by doctors with mental health problems for other doctors (and now medical students) with mental health problems.Even in this closed forum many doctors choose to remain anonymous because of their very real fear of stigmatisation by their colleagues/consultants/managers if their illness was known about. I worked as a consultant with quite a high profile whilst at the same time coping with dual mental health diagnoses. I would not have wanted to have an open profile on social media at the time for many reasons, but equally would have felt that I had a lot to offer.Five years ago I took early ill-health retirement from the NHS because of my illness. A couple of years before that I made a conscious decision to 'come out' to fellow doctors. I would not have thought it appropriate to do this to my patients. Indeed, ironically as a qualified psychotherapist my professional organisation bans me from using my real name in social media whilst actively practising, so if I was still working clinically I would effectively be banned from using social media!Since changing career I have been campaigning much more actively against the stigmatisation of people with mental health disorders, both inside and outside medicine. I have also been campaigning for increased social justice. I do not think it is an abuse of my profession to use the fact that I am a doctor to help with this, now that I am not in a position of working in one to one therapeutic relationships with patients.By the way I am old enough to believe that medicine is a vocation, and as such you can't 'stop' being a doctor when you leave the hospital and go home (nor for that matter when you retire). So in that respect I do agree with the GMC, you are committed to thinking about your behaviour and how it reflects on your profession until the day you die!

Thank you for sharing this. Have you ever encouraged doctors to use pseudonyms on open networks to discuss sensitive health issues? Like you I have also been part of closed forums in regard to some health issues I have had. But I would not want to start a pseudonymous account to discuss this publicly.

it is control. the GMC is not part of the profession, never mind offering the profession,'s view on professionalism. it is concerned with control and with branding and in due course with sale if that brand.

In terms of anonymity I have a 'solution' that would satisfy both the GMC and doctors alike. I think the 'problem' lies in self-identification and doctors' reasons for anonymity. For example, some doctors may use the moniker to 'speak' exclusively as a doctor on social media: 'primary' self-identifiers. However, some (most) doctors may use the moniker to speak as a doctor in a secondary manner on social media. These doctors may do so to enable them to 'identify' as a collective gaggle of doctors but not as an individual 'practising' doctor. As in, they are using their social media accounts to do more than be a doctor. To distinguish these 'use cases' I'd propose the use of 'Doctor' to represent the primary self-identifiers and 'doctor' to represent the secondary self-identifiers. I'd argue that Doctors must not be anonymous but that doctors could be anonymous.

Now, Joe Public may not be aware of this practice (they probably don't take everything a doctor currently says on social media to be 'true' either as is implied in the documentation) but, in the eyes of the GMC, you are clearly delineating your social media intentions.

People will have problems with my suggestion, I'm sure, but I thought I'd put it out there as an outside the box 'solution' to your impending problem.

Those of you who don't understand the internet should continue living in a world where fiction rules. Those of you who do understand the internet, will know that

1. There is no anonymity on the internet. Should the GMC wish and if there is a complaint, your identity can be extracted. Everyone leaves a footprint of their internet use.

2. With respect to the GMC, Ben Dean is wrong. The Human Rights Act is balanced with the Medical Act. The GMC has no right to privacy if the Medical Act - protection/safety of the public is a matter of "concern". The Human Rights Act and its application were tested in two cases - Pal v GMC 2004 and R v GMC Ex Parte Pal 2009. On each occasion, the judiciary agreed that public safety is paramount.

On Article 8, it is this caveat where the problem lies

"2. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others"

It is all well and good debating the rights of doctors. It would be feasible if the GMC addressed the fact that interests of doctors is relevant. They are though in the business of public protection. Their analysis of misconduct is arbitrary. They have a civil standard of proof now. Their ability to take up complaints is a lot easier than it ever has been.

Anyhow, argue on this all you all like. The fact remains, none of you read the case law or the way the GMC functions. You make speculative remarks based on your misunderstanding of the fact that doctors may have some rights. Accept the fact that so long as you are GMC registered, you have no rights.

I say again, "ooof". Definitely agree about the lack of anonymity online. I wonder what your opinion is regarding a doctor not identifying as such going about their merry business in public arenas (internet, societies etc), does the GMC still have the ability to come down on their behavior?

Yes they do :). There is a specific section in GMP that governs all circumstances. Rule 65 "You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession". It is the last part of this sentence that is wide open to interpretation.

If you look at isobel allen's report on the GMC. She states that the analysis of SPM [in those days] was arbitrary. It still is. There is a Committee discussion on it leaving the meaning of "misconduct" interpreted to fit "any circumstances". So, the test really is - does the Registrar or anyone who can influence the registrar at the GMC believe that the conduct complained of undermine's the trust in the profession. Now this is 1. Subjective 2. Undefined 3. The Registrar has no specific criteria.

The above describes "Conduct". The other more worrying part is "health". If the GMC believes that the doctor is developing a mental illness, they will collect all that is written by them. This has been seen in many cases.

In short, the GMC now have the right to do anything - including investigate a doctor without telling them.

I think that the public realise that doctors have personal views and that there would be the normal range of views as seen in the general population. Some views and some content, such as racy videos or insulting or discriminatory comments, are likely to cause offence to some people. If they are identifying themselves as a doctor (or any other profession) then consideration must be made as to whether the content would bring the profession into disrepute, judged by a body of peers I suggest. If yes, then the person posting should not be publicising their profession. The same criteria apply as with other conduct. They may not agree with this as one's personal perception is naturally biased.

As regards a doctor looking at page 3 in The Sun. Registering as a doctor does not require a good taste in newspaper choice or an absence of interest in soft porn! A good criterion is whether it is acceptable for an average member of the public to do so.

I worry about the constant inference of doctors lives outside their consulting rooms. The GMC has no right (sorry) to control what i do if it is not directly going to influence patients. My life on Social media is mine - with the caveats that we laid down on RCGP SoMe highway code. Doctors are professionals and hence act in that manner - if we transgress there are already enough avenues to seek redress from us. If a doctor wants to be anonymous on social media - so be-it (again see our highway code). Social media needs to develop and must not be nipped in the bud - its finding its way and we need to learn how to use it too its fullest- its like a pen- some can do harm with it , some bring joy.Clare

Clare, Is it not fair to say that RCGP and GMC have very different role and that the concerns they have may be different and therefore they take a slightly different view. I think what is missing from this debate is the fact that GMC or for that matter the government has no way by which it can stop people from impersonating as doctors on social media so the only way to do it is via this guidance. I think it is very ingenious. Anyone who claims to be a doctor but doesn't have a name is outed as a fake and anyone who does have a name can be checked on the register. Very clever indeed! Vishal @vgul

I understand that some people, as Anne-Marie said, just don't see the benefit in being anonymous and have never felt the need. But everybody uses social media in their own way, that's exactly what makes it interesting. I only joined Twitter three months ago. A lot of people start out anon then switch to their real name as they become more confident (and perhaps more senior). Maybe I will do that one day, but I'm not happy to do so yet. I want it to be on my own terms.

Especially as a junior doctor, you don't necessarily want to admit to the people you work with that you're tired or angry or you feel like you suck at your job some days. You grin and bear it because that's the culture and it's still not the done thing to show signs of weakness. Having a little anonymous outlet, and knowing that there are others who feel the same, is helpful to some people. I am ALWAYS calm and professional at work, but occasionally sweary ranty and flippant on Twitter. Being calm and professional at all times would get pretty knackering, to be honest. I would miss having that outlet.

Humour is a really important part of how I deal with stress. Some people don't understand this or think it's important, but everyone has their own coping mechanism and this is one of mine. I want to be able to joke about my job and be silly sometimes without worrying someone I know is going to take it the wrong way.

It's also nice to be able to talk freely about any contentious issue (politics, religion) without knowing that anyone in the world (employers, patients) could have access to all my thoughts simply by searching for my name.

And if I'm being perfectly honest here, I also enjoy being able to swear without worrying a potential future employer will see me calling Jeremy Hunt a f*ckface. I do realise swearing isn't a human right, and this is perhaps immature. But it makes me feel better.

I also really need to know patients won't be able to stalk me and find out where I am or what I'm up to. Maybe this seems unlikely, but I'm a girl in my mid 20s and I have had an actual stalker in the past who got arrested, so am perhaps unusually touchy about that particular issue.

I could make two accounts, one professional and one personal, but I hate having to cut my life in half. I am always a doctor, but I am always a person as well. I don't think we should be encouraged to completely separate out our personal and professional selves, it's not healthy. If I did have two accounts, am sure there are too many things that would fall into that gap, too personal for my 'doctor' account, too 'doctor' for my personal account. Also, I kind of want the lovely people I've met on Twitter to be able to get to know me. Who I am as a person influences who I am as a doctor, and makes me a better doctor. Who I am as a doctor makes me a better person.

If I ever actually needed to whistle blow or had a serious problem, of course I would use the proper channels. But for a little bit of a harmless rant, a little camaraderie and a little FUN, Twitter is an excellent medium and I think it would be a shame to take that away from people by forcing us to feel like we're constantly at work, on show, stethoscopes around our necks.

If everyone's tweets were private there would be very little interaction, and Twitter would be a boring place. I didn't know a single person on Twitter initially, so had I signed up with a protected account I would have exactly zero followers. The only reason I've become involved is through things I've said being retweeted and shared and commented on by strangers. If more doctors were scared into making their accounts private, the Twitter medical community would become pretty impenetrable to newcomers. Discussions would be had between small groups of people who know each other, limiting opportunities for everyone to contribute to debate. I've gained lots from interaction with other anonymous medic tweeters, learned stuff I would never have come across if their accounts were private, and I love it when I tweet something and a total randomer replies "me too!".

I also don't really see how having a private account would solve any of the problems I mentioned above. When you have hundreds of followers there's no way of knowing if one of them is a patient at your hospital, a stalky weirdo, or a consultant you might be confronted with on some future interview panel.

I am assuming here that if you were following the guidelines to the letter you would still have to reveal your identity even with a private account, since you are still addressing an audience of strangers involving members of the public (the only difference being that the GMC can't see what you're up to).

I am late tot his discussion but based on my knowledge of the healthcare profession I have made the following observations:

1. Most people seem to think that social media is a personal communication tool. Social media is a public tool, unless specifically restricted everything you say on SoMe is broadcasted to the whole world like a free to air television channel. SoMe output is actually more discoverable and persistant than television programmes. So now imagine that you are the owner of a medical news channel but you are not willing to say who is behind it. You think this is a viable option?

2. It seems to have gone unnoticed that this guidance has in one swoop made it very hard for people to impersonate doctors online. Which is a growing problem as we know. More details in my response to Clare above.

3. Can anyone please give me real examples of blogs/twitter accounts which are doing meaningful work in the interest of the profession which this guidance will stop? When I say meaningful, I don't mean people who are complaining that they will now have to watch what they say, I am afraid you should always exercise your judgement when broadcasting in public as a representative of the medical profession.

A medical TV channel would presumably be giving medical advice, which is something I (and most others) make it clear that I would never, ever do. If your account is specifically targeted at medical education or clearly designed to interface with the public on a medical topic, I totally agree that you must prove you know what you're talking about. The equivalent to your medical TV channel analogy would be a Twitter account entitled MEDICAL NEWS BY DOCTORS!! That's clearly nothing like what I'm doing here.

I wasn't aware that there was a big problem with people imitating doctors on Twitter. Is there evidence of that? Even so, surely it would be better to have a system whereby people could raise concerns about suspicious accounts, rather than have a heavy handed blanket rule applied to everyone. Unless the GMC is planning to check and verify every single doctor's account, it isn't going to provide much of a guarantee.

Also, can you define 'meaningful work'? Humorous, pseudonymous accounts like The Med Reg on Facebook have tens of thousands of followers, generate a lot of debate and make people laugh. I suppose it depends whether you think laughter is important.

My Twitter account may be utterly irrelevant to the rest of the world, but as I've already explained, it serves a meaningful purpose for me.

I'm a GP and I'm appalled at the GMC's ruling on this. Before I'm a GP I'm a person with interests, beliefs and feelings. These feelings will include views on abortion, euthanasia, animal experimentation, homeopathy, religion, politics, veganism, tattoos, haircuts and pretty much everything. Naturally I know I should not bring these views into the consulting room or let them make me discriminatory or judgemental in my treatment of patients, plus I should also be aware that a patient who, say, has much faith in homeopathy might be needlessly irritated or offended by my private views on it. So as far as work is concerned, I keep a Chinese Wall up - this is for the benefit of my patients who can see me as the neutral person I am in the consulting room, and also for the benefit of my privacy (the patients have no right to know my private thoughts and beliefs).

However, in private, whether it is in the pub, at a social gathering or on the internet, if I want to have a natter or debate my views, then I should be allowed to do so. Online, if I am compelled to identify myself then I open myself up to irritating or worse patients who disagree - how can that be helpful to either them or me? I also expose myself to internet nutters (eg animal rights activists) with extreme views who might stalk and harm me, or initiate a vexatious vendetta with the GMC. If, say, I'm a supporter of UKIP and I am GP in Rotherham, identifying myself clearly compromises me in my role in child protection. There are all manner of perfectly legitimate, legal and reasonable views, which, if expressed will upset *some* patients, and invite flak from a minority of them.

I'm a human being before I'm a GP. Some time ago a relative was terminally ill and I participated anonymously in social media, covering controversial subjects and also the various failures of care this person had. This was very helpful to me as a source of support and I was anonymous regarding myself and the relative. It was relevant to state I am a doctor in this conversation with others - but had I been obliged to identify myself, my patients would have known about deeply personal things, which would been stressful to bring into the consulting room, plus I would have been in the minefield of being seen to publicly undermine the NHS, so would I have been in trouble from the various authorities? Or, more worryingly, quietly noted by them as someone to watch and jump on the moment I give even the mildest opportunity?

The internet is a minefield and doctors who post online already have to be very careful. If we were to post anything libellous or deeply offensive there are already laws which will identify and punish us, plus as doctors we would then be publicly humiliated in the media reported to the GMC. This is more than enough to make us responsible. However that responsibility should not undermine our own privacy as people. I'M ALLOWED TO HAVE MY THOUGHTS!

Jonathon Tomlinson aka @mellojonnyI joined twitter in 2009 anonymously. Like most people I had to be on it for a little while to figure out how it worked. I chose mellojonny because Lance Armstrong had just opened a bike shop with the same name, and though I wasn't an Amstrong fan (by any means) I was racing regularly and thought I'd get in with mellojonny before he did.

Initially I wanted (like most people) to use twitter to broadcast my concerns about what was happening to the NHS, Labour were setting it up as a gift for the Tories, ripe for privatisation. I wanted to use twitter as a tool for awareness raising and sedition. Fortunately for me I was secure in a GP partnership and lacked any political ambition so I had (or so I thought) nothing to fear from speaking my mind. I decided early on to use my real name because I thought it would give me more credibility, I would make me think more about what I posted and because I thought that at some point someone would discover my identity anyway.

Because of my opinions I have been attacked on several occasions and have a reputation as a trouble-maker, Trotskyist, Commie, Unionist, etc. etc. not just by anonymous users but by powerful and deeply unpleasant policy makers and political representatives. I wrote a blog explaining my conflicts of interest http://abetternhs.wordpress.com/about/ to save people the trouble of digging around and posted a picture of me waving an anarchist flag: http://abetternhs.wordpress.com/2010/12/11/doctors-not-protesting/

Twitter is for the most part incredibly supportive and I can be (am) more political there than I am amongst my friends, very few of whom are as fired up as I am.

As a politically active doctor I think it is vital to use my identity, but I say that as a GP in a secure partnership with academic ambitions. Speaking truth to power is very different if you are coming from a different, less powerful perspective.

The most eloquent, active and interesting patient advocates I have met on twitter are in relation to #mentalhealth. Many of them choose to use social media anonymously and are no less effective for it, e.g. @_sectioned I know that she had a terrible experience in hospital as have other members of her family. She chooses to use twitter to learn about, advocate for and support other users who have experienced and understand mental health problems. For all I know, she might be a doctor. I would hate for her identity to be revealed.

We choose to use twitter for different aspects of our lives. I worry for anyone who thinks that their identity is secure and would always caution against an anonymous account, but the supportive role of social media is extraordinary and I would hate for those who use it for the generosity of spirit and great kindness that exists - no less than a life-line, to be frightened away by the GMC ruling.

Dear Anne,Thank you for opening up what clearly has been fantastic source of debate. Personally, have had no qualms about using my own name as never needed anonymity to use any of the social media forums I use. Even on facebook, I am myself- but perhaps with a limited circle with privacy settings. Having said that issues such as whistle blowing etc are important but my personal view is "each to their own". There are however examples when black humour, jest simply crosses the line- and I suspect is easy to do when one sits behind the shield of anonymity.Point in case: look at this link: https://www.facebook.com/medicalreg?fref=ts especially one on Mar 12. Black humour? Poor taste? Funny? Outrageous? Its exactly here where it all gets murky- I suspect whoever the contributor is (is he or she a doctor?) would hesitate doing so under their own name.

Another one? Read responses to my bit in hospitalDr. http://www.hospitaldr.co.uk/blogs/partha-kar/real-accountability-would-root-out-the-skivers#comments

Easy to snipe from behind anonymity? Perhaps. Perhaps not. Just the other side to the debate which also highlights the importance on non encroachment of personal life, the ability to raise issues anonymously

The debate will continue- but as a guidance, not a diktat,in my opinion it isn't a bad one.

Many people are worried that the Medical Registrar may fall foul of this guidance. Like yourself, I sometimes feel uncomfortable with what is posted. However I recognise that most of the activity on these pages does not take place under a pseudonym, as most of the doctors liking and commenting are using their real names.

The GMC should have enough to do with doctors who, for example, promote their own evidence free/lacking interventions to people, or who don't disclose their financial incentives for promoting commercial interests. There are doctors who will cheerfully recommend, say, vaginal cosmetic surgery to young women without telling them that they are normal; there are doctors who allow pharmaceutical companies not to publish their research, doctors who have published research on patients who don't exist. There are so many real problems that it's hard to understand why the GMC are so worried about 'anonymous' doctors online.

Say I want to write about being ill, or knitting, or writing poetry, or living in Glasgow, or a family issue, or a holiday; I can't stop being a doctor for any of those things. Being a doctor influences the rest of my life. We need to move away from the god-like paternalistic idea of The Doctor and start talking about margaret who is also a doctor.

This does not excuse doctors from going online to be racist, or homophobic, or potentially breach confidentiality - it shouldn't mean that live tweeting a days' work is ever a good idea , see this piece here http://www.bmj.com/content/346/bmj.f54?ijkey=DVioWQm1I2eITA6&keytype=refbut disallowing anonymous accounts and shutting down free speech is potentially dangerous.

There are dozens of anonymous online folk I follow and learn from. The division of concern shouldn't be between anonymous and non anonymous online doctors. It should be between doctors with undeclared conflicts of interests and doctors without, or be between doctors who act professionally and doctors who don't. The GMC should be concentrating their guidance and resources to sort this out, and leave the rest alone.

You blog and tweet in your own name. Do you interpret the GMC guidance as saying that you shouldn't talk about knitting or poetry? Or do you, as other doctors have said, feel that this is something that you don't want to reveal to patients? Would having a pseudonymous account make that easier for you?

It seems we have a bit of muddled thinking about showing this human side of medicine. People think it is important but feel awkward doing it in their own name.

HiI think that both Margaret and mellojonny are spot on. Obviously none of us are advocating tweeting or blogging about our patients; anonymously or otherwise. That would clearly breach every professional rule there is.Jonny refers to mental health and rightly cites tweeters such as @sectioned_ and others, some known to be doctors and others undisclosed. It is easier tho still taking big personal risks to tweet openly as a doctor with significant mental health issues if you are senior, securely employed, and confident about your diagnosis. All of those apply to me, and as I am now in academia in a different city from that in which I had patients there is no risk of being in a therapeutic role with a patient who suddenly discovers that I am tweeting about my bipolar disorder. I firmly believe that such discovery could be damaging to a therapeutic relationship. This is nothing to do with thinking that doctors are perfect, or that patients should think that their doctors do not get ill. Imagine if I were to discover now, via social media, that my psychiatrist had schizophrenia. It would shift the ground of our 12y relationship dramatically. There are times when planned disclosure is appropriate, but this requires senior and experienced doctors and carefully selected patients.I can see every reason why trainees and newly appointed consultants with personal illness, especially mental illness, should wish to tweet anonymously, and indeed I would argue that they are fulfilling the duties of a good doctor by doing so. Honest tweeting about one's own experience of illness can help, inform, and educate people that you might never meet.

I know some doctors who have shared publicly that they are living with mental illness. I don't think you are saying that this is always wrong but I would like to state clearly that I think that the choice of disclosure is up to the doctor.

Sorry to be slow joining this discussion - I've had a few technical issues and have taken some time to formulate my thoughts on this.

I think that Margaret McCartney hits the nail on the head. Though most of the discussion has been about anonymity, the key issues here are professionalism and accountability. I can understand why many doctors would wish to be anonymous; I have chosen to tweet in my own (slightly unusual) name and try to choose my words very carefully - I may still come to regret this at some point in the future. It will be a great shame if the 'anonymity' guidance from the GMC drives large numbers of doctors away from social media. The vast majority of anonymous doctors are clearly able to self-regulate and uphold the same high professional standards as they maintain in their ‘identified’ lives; unfortunately there is a small minority who are failing to do this.

There is an increasing number of Facebook sites on which anonymous ‘doctors’ (and other healthcare professionals) post regular comments identified only by their speciality or grade. Many of the comments are humorous or satirical and they will often stir up interesting and useful debate. However on occasions their posts have been unprofessional, abusive and disrespectful to other healthcare professionals, other medical specialities, and certain patient groups.

Such comments may be vented at moments of private frustration, behind closed doors, or in the confines of the doctors' Mess - but Social Media is not the Doctors' Mess. Doctors currently still hold an influential position in society; views expressed in a public forum may have unintended – and potentially serious - consequences, if the humour, irony or satire is not appreciated.

Of course we cannot be certain that these individuals are doctors, and some may be 'groups' rather than individuals. However there needs to be accountability for those registered healthcare practitioners whose professional status is revealed, and it is hard to see how accountability can be assured without identification.

The current guidance remains ambiguous – ‘identified by name’ could be interpreted in a number of ways. One doctor has expressed concern that she may fall foul of these regulations by tweeting in her married name – instead of her maiden name which she uses in her professional life. Those doctors with common names would remain relatively difficult to identify, and verification of identities will be extremely complex to police.

Maybe the GMC should consider maintaining a confidential register of anonymous identities, accessible in the case of a complaint but otherwise providing protection to those who wish their names to remain hidden? For a small fee, perhaps….?

If there is no harm done by not revealing oneself to be a doctor, it should be up to the doctor to decide when they want to be named or not.

It's also not about what I want to 'reveal' or be showing how I'm 'being human' to patients. It's about being able to be a doctor and also to have relationships which are independent of that fact. Why can't I 'happen' to be a doctor in many part of my life, rather than being The Doctor? It's absurd to think that I should somehow declare myself a doctor when it's irrelevant or when my behaviour doesn't give cause for concern.

I don't think this is muddled; I think the GMC are muddled. Like I said the anonymous doctor is not, by itself, a problem. There are plenty of doctors acting in their own name who the GMC should be concerned about; the Venn diagram here should not be one where concerns are divided into anonymous or not, but professional or not, or undeclared interests or not.

As I said of course you are right that the GMC should be concerned about doctors being unprofessional or not disclosing conflicts of interest.

I don't think that this guidance asks people to declare they are a doctor when it is irrelevant. And I don't think it stops doctors having relationships online which are independent of being doctors.

I have read doctors saying that they write using a pseudonym so that they do not have to argue with patients about their taste in music. In a few weeks I will be seeing Efterklang. I might well tweet when there. Will I worry that a patient mentions this to me the next morning? No. I do not share publicly what I mind addressing with patients, students, and colleagues or the rest of the public. But in my experience, my taste in music is not of very much interest to others, and especially not to patients who have a whole lot more on their minds.

If other doctors want to use a pseudonym to stop the risk of these conversations then so be it. It is up to the GMC to clarify their guidance but I would doubt if they have an issue with it either.

People often want to keep parts of their life private from others. That is very sensible and their right.

"Do you interpret the GMC guidance as saying that you shouldn't talk about knitting or poetry? Or do you, as other doctors have said, feel that this is something that you don't want to reveal to patients? Would having a pseudonymous account make that easier for you?"

The point is that if you didn't want your patients to know that it is you tweeting or blogging about knitting or poetry, you might choose to do this anonymously; but if your blog ever mentioned that you were are doctor, you would be in breach of GMP guidelines, and "your registration may be at risk" as a result.

It is hard to imagine that this is what the GMC intended; it looks like badly worded, ill-thought-out, rushed-through guidelines.

I doubt that many of us who object to the GMC's wording really object to its intentions (unless rather paranoid-sounding - but not implausible - concerns are true: that the GMC is acting as an agent of the state, working to control the dangerously knowledgeable professionals who are the state's strongest opponents).

What most of us would like to see is a reversion to the original wording - which probably says what the GMC really intended.

Huge issues here - and a very good set of comments. The use of anonymity has a great many advantages, many of which have been alluded to in the comments so far. I have a couple of things to add.

1) One of the big questions I have to ask is why it's even necessary to ask for people to give their real names? If people misbehave, it IS possible to lift the veil of anonymity, both legally and practically. Norwich Pharmacal orders can be (and have been) used to get subscriber information. What's more, most forms of social media have strong self-policing systems - and if a 'doctor' is abusing their position on social media, they will get the treatment that their misbehaviour deserves.

2) Secondly, and more importantly, many (and perhaps most) people aren't able to (and shouldn't be asked to) separate their 'professional' lives from their personal lives. I tweet and blog in all capacities - I'm an academic lawyer, but I'm also a football fan, a husband, a father, someone with strong political views etc etc. I don't compartmentalise my life that clearly - and if I tried to, I'd probably fail. That means that if I was bound my similar guidance, it wouldn't just be my 'professional' tweets and blogs that were covered, but all of them.

Anonymity and pseudonymity are a key factor in real freedom of speech - they stop the chill that can come from potential reprisals from authorities and enemies. They allow people to give out crucial information and valuable insight that would otherwise be lost. For doctors, that could be particularly important, especially with the profession under threat from the NHS 'reforms' and so forth. Those of us who are not in the medical profession would lose just as much - personally, I've found tweets and blogs from doctors, nurses, social workers, probation officers, police officers etc of great interest and value. I don't want to lose that - and enforcing identification could have that kind of effect. The 'Nightjack' saga is a cautionary tale here.

I agree in most other ways with the GMC guidance - and it wouldn't take much to 'tweak' what they say about anonymity, tilting it back to 'advice' that applies with a LOT of exceptions, into something good. It's a shame they haven't done so.

What about doctors who act anonymously outside social media? Why is it fair that you have to give your name if you post something on social media, if you can publish an anonymous review article in a traditional journal? Or, as a journal reviewer, provide anonymous feedback to authors submitting articles for publication?

And what about other activities undertaken anonymously such as forum moderation?

See http://peterenglish.blogspot.co.uk/2013/03/the-gmc-and-guidance-for-anonymous.html#TradMedia

Firstly I am not a doctor and have a number of roles and interests within my local community. My main and only source of income is from Novartis and I work in Global R&D. Anne Marie, I have found this debate enthralling. I am keen that many actors in the health conversation are moving to a more open collaborative culture which will be of benefit to patients, and there may a paucity of evidence to show this right now.One of the aspects to add to this discussion is the network effects of twitter and other social media. There is clearly a different component to the odd anonymous tweet about some health care issue vs the lengthy broadcasts (spam to some other people) of anonymous tweets to the interactive participative anonymous tweeters with a broad following and clearly adding meaning and matter to the health conversation.Hence the need to see anonymous tweeters not as sole atoms in Brownian motion of twitter but rather how their “tribe” interact and hence produce a dominant narrative. I am unaware of any research as to how anonymous tweets are followed / responded to and how this may change the course of the discussion. Clearly this network effect could be used to a positive (for patient care) end or even negative end which I hope any professional group would be able to say is inappropriate

Such a fascinating range of views and suggestions about the new guidance and how it will apply to currently blogging and tweeting anonymous doctors. It's somewhat reassuring to see the clarifications that the GMC have put forward, but I suspect the issue is unlikely to fade so quickly. I've always tweeted under my own name and identifying as being a doctor essentially with the awareness of Twitter being public domain. It was never a particularly conscious decision, but I felt that I would probably not be saying anything terribly controversial anyway! I find this makes it easier to establish the level and content that I would post, comment on and retweet; however maintain vigilance of this is pretty difficult. I would need to download the archive of the 100 or so tweets I've made to determine what the cumulative disclosure of e.g. personal views, location and the like are out there, and it is something that I think everyone on line forgets and inevitably loses track of. But I certainly modify twitter content compared to what I might share on Facebook, where I do not say that I am a doctor (although the majority of my friends are already aware of this fact anyway, adding to the perplexity of the guidance). I find the GMC guidance ultimately confusing and I suspect there will be considerable debate if and when hearings are brought against people about the rights to a private life and correspondence. I would hope that common sense will prevail in the end as we all accumulate on-line lives and identities, but this is yet to be worked out in society in general and will take time to percolate through into the older generations and the formal regulatory structures that we have - e.g. Judicial system and professional bodies.